1. Study suggests graphic anti-smoking posters may actually backfire

    December 30, 2017 by Ashley

    From the RAND Corporation press release:

    Exposing teens to graphic anti-smoking posters may actually increase the risk that some start smoking, according to a new RAND Corporation study.

    Conducted in a one-of-a-kind laboratory that replicates a convenience store, the study found that some teens who viewed posters depicting gruesome displays of smoking-caused diseases actually reported being more susceptible to cigarette smoking after viewing the displays during a shopping trip.

    The negative effects were found among teens who, before viewing the posters, reported being at some risk for smoking. The graphic posters did not appear to have any effect on teens who were committed to never smoking.

    “Our findings are counter intuitive and suggest that some anti-smoking strategies may actually go too far,” said William Shadel, lead author of the study and a senior behavioral scientist at RAND, a nonprofit research organization.

    The study is published online by the journal Nicotine & Tobacco Research.

    Most of the tobacco industry’s advertising spending is focused on point-of-sale retail locations such as convenience stores. These outlets are awash in posters for tobacco products, signs for price promotions and the tobacco power wall — the display of cigarettes and other tobacco products that is prominent behind the checkout counter.

    Studies indicate that most adolescents visit locations that sell tobacco on a near weekly basis, placing them at significant risk for repeated exposure to tobacco advertising. Numerous studies have linked such exposures to more-positive attitudes toward smoking among adolescents.

    In response, some jurisdictions have proposed that graphic cigarette warning posters be displayed alongside the tobacco power wall and near the cash register. New York City mandated such warnings in 2009, but courts voided the regulation after lawsuits initiated by the tobacco industry.

    For the RAND study, researchers had teens visit a replica of a convenience store to buy a few items. With about half of the teens, the checkout counter or the wall behind the cash register displayed a prominent poster showing a photo of a diseased mouth and the words “WARNING: Cigarettes cause cancer.”

    The poster used was drawn from among nine that the U.S. Food and Drug Administration had intended to put on cigarette packages and was the one had been rated as the most effective image by adolescents in previous research.

    The 441 adolescents aged 11 to 17 who participated in the RAND experiment were surveyed about their attitudes toward cigarette smoking and asked about other items both before and after shopping in the replica convenience store. About 5 percent of the participants reported prior cigarette smoking and about 20 percent were considered at-risk for future cigarette smoking before visiting the convenience store.

    Researchers say their analysis found that rather than disrupting the positive point-of-sale advertising in the convenience store, the graphic anti-smoking poster seemed to further heighten the smoking susceptibility of adolescents already considered at-risk for future tobacco use.

    “It is possible that at-risk adolescents responded to the graphic warning posters in a defensive manner, causing them to discount or downplay the health risks portrayed in the poster,” Shadel said. “It may also be possible that the graphic posters caused adolescents to divert their attention to the tobacco power wall, where they were exposed to pro-tobacco messages.”

    Researcher say that a shortcoming of their study is that they tested only one anti-smoking poster with the adolescents and they did not experiment with a variety of poster sizes or a greater variety of store placement.

    “Our findings do suggest that policymakers should be careful when considering graphic warning posters as part of anti-tobacco education in retail environments,” Shadel said. “This type of action either needs additional research or potentially should be abandoned in favor of better-demonstrated anti-smoking efforts.”


  2. Study suggests health warnings on cigarettes could deter young people

    December 21, 2017 by Ashley

    From the Cancer Research UK press release:

    Young people are less likely to try cigarettes with the printed health warning ‘Smoking kills’ on each stick than standard cigarettes, according to a new study by Cancer Research UK published in Nicotine & Tobacco Research.

    Researchers wanted to examine new, innovative ways to reinforce health messages around smoking. They surveyed nearly 1000 16-24 year olds from across the UK to evaluate their response to different cigarette designs.

    A health warning on the side of each cigarette meant young people — including smokers and non-smokers — were around three times less likely to want to try them than standard cigarettes. Smokers were the most put off by them.

    Young people also said that green cigarettes were less tempting than standard cigarettes.

    Smoking tobacco is the biggest preventable cause of cancer in the UK and the leading cause of preventable death. While smoking rates among young people in the UK are going down, one in every six 16-24 year olds is a smoker in Great Britain. And in Scotland a fifth of all 16-24 year olds smoke.

    Dr Crawford Moodie, Cancer Research UK-funded scientist and lead author said: “The study shows how cigarettes can be an important communication tool and that altering their appearance, with a health warning or an unappealing colour, can make them less desirable. Young people who start smoking are likely to continue to do so into adulthood, so anything that may deter smoking among this group could help to tackle the potential health repercussions in later life.”

    George Butterworth, Cancer Research UK’s senior policy manager said: “Too many young people are still taking up smoking in the UK. Government anti-smoking campaigns and tax rises on cigarettes remain the most effective methods to stop young people starting. We need to continue to explore innovative ways to turn young people off cigarettes to ensure that youth smoking rates continue to drop. This study shows that tactics like making the cigarettes themselves unappealing could be an effective way of doing this.”


  3. Study suggests e-cigarettes more likely to be used by alcohol drinkers and former cigarette smokers

    November 25, 2017 by Ashley

    From the American Heart Association press release:

    Electronic cigarettes are more frequently used by people who recently quit smoking and alcohol drinkers, according to preliminary research presented at the American Heart Association’s Scientific Sessions 2017, a premier global exchange of the latest advances in cardiovascular science for researchers and clinicians.

    Researchers examined data from 5,423 individuals with recorded tobacco use in the 2013-2014 National Health and Nutrition Examination Survey (NHANES). A total of 116 (2.6 percent) of NHANES participants were found to use e-cigarettes.

    They found electronic cigarettes were used by 8 percent of people who never smoked. When compared to individuals who never used any tobacco products, e-cigarette users were:

    • 6.32 times as likely to be exposed to second-hand tobacco smoke.
    • 4.19 times as likely to report drinking alcohol 12 times or more in the last 12 months.
    • Less likely to be college graduates, illicit drug users and people with an income of at least $75,000.

    Compared to other tobacco users, e-cigarette users were more likely to be current or former smokers. Former smokers were 23 times likely to use e-cigarette, within the last three months of quitting cigarettes.

    With an observed trend, the longer the time duration since quitting cigarettes, the lower the difference was between e-cigarette users and other tobacco users. However, the difference remained large and significant for all time intervals, researchers said.

    The American Heart Association cautions against the use of e-cigarettes, stating that e-cigarettes containing nicotine are tobacco products that should be subject to all laws that apply to these products. The association also calls for strong new regulations to prevent access, sales and marketing of e-cigarettes to youth, and for more research into the product’s health impact.


  4. Study looks at how gut and gender may affect ease of quitting smoking

    November 6, 2017 by Ashley

    From the American Chemical Society:

    Many people who smoke or chew tobacco can’t seem to escape nicotine’s addictive properties. Studies show that women in particular seem to have a harder time quitting, even with assistance, when compared to men. Now, scientists report in a mouse study published in ACS’ journal Chemical Research in Toxicology that the difference in gender smoking patterns and smoking’s effects could be due to how nicotine impacts the brain-gut relationship.

    Cigarette smoking has long been a major public health issue. It’s related to one out of every five deaths in the U.S., according to the U.S. Centers for Disease Control and Prevention. When a person smokes tobacco, nicotine is delivered mainly to the lungs. But with skin patches and chewing tobacco, nicotine crosses the skin and into the gastrointestinal tract, respectively. Previous research has shown that nicotine and the nervous system interact, producing a number of effects including the release of the “feel-good” chemical dopamine. Studies have also shown that the effects of nicotine are gender-dependent. To more fully understand why this is, Kun Lu and colleagues wanted to explore how nicotine affects male and female gut microbiomes.

    The researchers set up a 13-week experiment during which they administered nicotine-infused water to mice. An analysis of the animals’ fecal samples showed major differences in the composition of the microbiomes in male and female mice. Levels of compounds and bacterial genes associated with the nervous system and body weight were altered in different ways in male and female mice. For example, the mice exposed to nicotine, especially the males, had lower concentrations of glycine, serine, and aspartic acid, which could weaken the addictive effect of nicotine. In addition, nicotine-treated female mice had reduced amounts of Christensenellaceae bacteria, while the treated male mice had increased levels, which are associated with a lower body mass index. The team says future efforts will focus on exploring the relationship of the nicotine-gut-brain interactions on a molecular level to further understand the communication paths involved.


  5. Study suggests effectiveness of online social networks designed to help smokers quit

    November 1, 2017 by Ashley

    From the University of Iowa press release:

    Online social networks designed to help smokers kick the tobacco habit are effective, especially if users are active participants, according to a new study from the University of Iowa and the Truth Initiative, a nonprofit anti-tobacco organization.

    The study examined the tobacco use of more than 2,600 smokers who participated in BecomeAnEX.org, Truth Initiative’s online smoking cessation community designed in collaboration with the Mayo Clinic. The study found that 21 percent of those classified as active users after their first week in the community reported that they quit smoking three months later. Those who were less active in the community were less likely to quit.

    Kang Zhao, assistant professor of management sciences in the UI Tippie College of Business and the study’s co-author, says the results show that online interactions can predict offline behavior.

    How central you become in the online social network after the first week is a good indicator of whether you will quit smoking,” says Zhao. “This is the first study to look at smokers’ behaviors in an online community over time and to report a prospective relationship between social network involvement and quitting smoking.”

    The BecomeAnEX website enables members to share information and support through blogs, forums, and messages. Although the site is focused on smoking cessation, users can post on any topic. More than 800,000 users have registered since the site launched in 2008, resulting in a large, active community of current and former tobacco users supporting each other.

    Funded by the National Cancer Institute, the study constructed a large-scale social network based on users’ posting habits. Zhao says a key finding was that increasing integration into the social network was a significant predictor of subsequent abstinence. Three months after joining the BecomeAnEX social network, users who stayed involved on the site were more likely to have quit smoking when researchers contacted them to assess their smoking status.

    After three months, 21 percent of active users — or those who actively contributed content in the community — quit smoking; 11 percent of passive users — those who only read others’ posts — quit smoking; and only 8 percent of study participants that never visited quit smoking.

    The study did not examine why greater community involvement had such a positive effect on smoking cessation. Researchers speculate it may be because of powerful social network influences.

    “Spending time with others who are actively engaged in quitting smoking in a place where being a nonsmoker is supported and encouraged gives smokers the practical advice and support they need to stay with a difficult behavior change,” says Amanda Graham, senior vice president, Innovations, of Truth Initiative and lead author. “We know that quitting tobacco can be extremely difficult. These results demonstrate what we hear from tobacco users, which is that online social connections and relationships can make a real difference.”


  6. Managing negative emotions can help pregnant smokers quit

    September 28, 2017 by Ashley

    From the University at Buffalo press release:

    A new study by scientists in the University at Buffalo’s Research Institute on Addictions has shown that pregnant smokers are more likely to quit if they can learn to manage negative emotions that lead to smoking.

    Smoking during pregnancy is a matter of serious concern, says Clara Bradizza, PhD, senior research scientist at RIA.

    “It’s well-documented that smoking cigarettes while pregnant leads to a range of negative health effects on fetuses, including increased risk of low birth weight and preterm delivery, and greater rates of asthma and learning disabilities,” she says.

    The research involved 70 pregnant women who wanted to quit smoking and reported smoking in response to stress, anger and anxiety. “These women use smoking as a way to manage their negative feelings,” Bradizza says. “Many experience poverty, insecure housing and unemployment, along with the stress of pregnancy, which increases negative emotions. All these factors make it more difficult to quit.”

    Half of the women took part in a smoking cessation program consisting of emotion regulation treatment (ERT) combined with standard cognitive-behavioral therapy (CBT), while the others received CBT and a control treatment consisting of health and lifestyle education.

    “ERT is an exposure-based therapy where counselors help participants imagine stressful situations that elicit strong urges or cravings to smoke, and then allow them to experience these feelings in session, without smoking. The women were also taught mindfulness skills and effective ways to cope with urges to smoke,” Bradizza says.

    The women who took part in the ERT program showed significantly higher rates of smoking cessation, with 23 percent remaining smoke-free two months after beginning ERT treatment, compared to none in the control group. They also reported feeling more confident they could remain abstinent from smoking. In addition, the women in the ERT program who did not quit smoking showed improvement, as they smoked less than half the number of cigarettes daily as those in the control group.

    Because smoking cessation medications such as Chantix (varenicline) are not recommended for use in pregnancy, there is a greater reliance on behavioral treatments to help pregnant smokers quit. Bradizza plans a larger trial of the ERT program to help further develop a new approach that is critically needed to help pregnant women quit.


  7. Study examines impact of nicotine reduction on vulnerable smokers

    September 7, 2017 by Ashley

    From the Larner College of Medicine at the University of Vermont press release:

    The FDA is right — when it comes to disease culprits, cigarette smoking tops the list. While recognized as the number-one cause of preventable disease and death, it’s an incredibly tough habit to break due to the addictiveness of nicotine. New research from the University of Vermont (UVM) and colleagues suggests that reducing nicotine content in cigarettes may decrease their addiction potential in especially vulnerable populations and suggests how regulatory policies could shift preferences to less-harmful tobacco products.

    The study appears in JAMA Psychiatry.

    The Vermont Center on Behavior and Health (VCBH) at UVM focuses on the relationship between behavior and health, particularly in disadvantaged populations, a group that is “overrepresented” among smokers, according to the study’s authors. In their latest study, the research team, led by Stephen Higgins, Ph.D., professor of psychiatry and VCBH director, examined the addiction potential of cigarettes with reduced nicotine content in three vulnerable populations of smokers — individuals with psychiatric disorders (i.e., affective disorders, opioid-use disorder), and socioeconomically disadvantaged women.

    Evidence in relatively healthy and socially stable smokers indicates that reducing the nicotine content of cigarettes reduces their addictiveness,” says Higgins. “Whether that same effect would be seen in populations highly vulnerable to tobacco addiction was unknown.”

    The multi-site, double-blind study is “the first large, controlled study to examine the dose-dependent effects of cigarettes with reduced nicotine content on the reinforcing effects, subjective effects, and smoking topography of vulnerable populations,” say the study’s authors.

    The study ran between March 2015 and April 2016 and included 169 daily smokers, including 120 women and 49 men. Participating centers included UVM, Brown University, Johns Hopkins University School of Medicine and the University of Kansas. A total of 56 of the participants were diagnosed with affective disorders, 60 with opioid dependence, and 53 were socioeconomically disadvantaged women. Each study participant completed fourteen 2- to 4-hour sessions, abstaining from smoking for 6 to 8 hours before each of the sessions, which were organized in 3 phases. Phase 1 included sessions 1 to 5 and included sampling of the research cigarettes in double-blind conditions, beginning with the smoking of the participant’s regular brand cigarette in session 1 and then smoking 1 research cigarette of identical appearance, but varying doses of nicotine in sessions 2 to 5. Participants were required to use a plastic cigarette holder when smoking research cigarettes, in order to measure smoking topography — number of puffs, length and speed of each puff.

    A Cigarette Purchase Task (CPR) was completed after each smoking session to measure the effects of cost on the participant’s rate of smoking. Additional questionnaires assessed research cigarette evaluation, nicotine withdrawal, smoking urges, and nicotine dependence.

    The Phase 2 sessions (6-11) provided participants with an opportunity to select which cigarette they preferred to smoke among 6 different dose combinations and used a computer program, which recorded which of two cigarettes participants preferred for that session and whether or not they wanted to continue to smoke that selection after two puffs or abstain. The final phase 3 (sessions 12-14) followed the same protocol, but measured only the highest and lowest doses of nicotine.

    While participants tended to prefer the higher nicotine dose content research cigarettes, the researchers found that the low-nicotine dose cigarettes could serve as economic substitutes for higher-dose commercial-level nicotine cigarettes when the cost of the latter was greater.

    Among the limitations of the study is its brief exposure to the research cigarettes. The authors report that field testing of extended exposure with these vulnerable populations to determine feasibility under “naturalistic smoking conditions” is underway.

    “This study provides a very encouraging indication that reducing the nicotine content of cigarettes would help vulnerable populations,” Higgins says. “We need more research, but this is highly encouraging news with tremendous potential to improve U.S. public health.”


  8. Smokers 20 percent more likely to quit when cigarettes cost $1 more

    September 3, 2017 by Ashley

    From the Drexel University press release:

    Older smokers are usually more set in their ways, but a dollar increase in cigarette prices makes them 20 percent more likely to quit, a new Drexel University study found.

    The study, published in Epidemiology, used 10 years of neighborhood-level price data to determine how it affected nearby smokers, focusing on those who skewed older.

    Older adult smokers have been smoking for a long time and tend to have lower rates of smoking cessation compared to younger populations, suggesting deeply entrenched behavior that is difficult to change,” said Stephanie Mayne, PhD, the lead author of the study who is a former doctoral student at Drexel and now a fellow at Northwestern. “Our finding that increases in cigarette prices were associated with quitting smoking in the older population suggests that cigarette taxes may be a particularly effective lever for behavior change.”

    Taking a look at the local relationship between smoking habits and cigarette prices is an understudied but important area to look at, according to the senior author on the study, Amy Auchincloss, PhD, associate professor in the Dornsife School of Public Health.

    “Results on this topic primarily have come from population surveillance,” she said. “But we had neighborhood tobacco price data and could link that to a cohort of individuals who were followed for about 10 years.”

    Smoking cessation remains an important focus of public health efforts since it remains the largest preventable cause of death and disease in not just the United States, but the world.

    The cohort Mayne and Auchincloss looked at included smokers ranging in age from 44 to 84 and stretched across six different places, including the Bronx, Chicago, and the county containing Winston-Salem, North Carolina. Data were taken from the study population between 2002 and 2012 as a part of the Multi-Ethnic Study of Artherosclerosis (MESA).

    In addition to finding that current smokers were 20 percent more likely to quit smoking when pack prices went up by a dollar, Mayne and Auchincloss’ team showed that there was a 3 percent overall reduction in smoking risk.

    However, when the data was narrowed to heavy smokers (defined as smoking more than half a pack a day), there was a 7 percent reduction in risk. When prices increased by a dollar, heavy smokers also showed a 35 percent reduction in the average number of cigarettes they smoked per day, compared to 19 percent less in the overall smoking population.

    “Since heavy smokers smoke more cigarettes per day initially, they may feel the impact of a price increase to a greater degree and be more likely to cut back on the number of cigarettes they smoke on a daily basis,” Mayne said.

    While the data focused on a population older than 44, Mayne believes the price effect may be “similar or possibly stronger in a younger population.”

    “Some research suggests younger adults may be more price-sensitive than older adults,” she pointed out.

    Something she found, though, was that smoking bans in bars and restaurants did not appear to have any effect on smoking behavior in the study population. Although more research is likely necessary to see why that is and whether it’s true — Mayne will soon publish a study devoted to that — one possible explanation is that the economic pressures of a cigarette price increase provide a stronger incentive to quit than placing limits on smoking in public places.

    Mark Stehr, PhD, an associate professor in Drexel’s School of Economics who also served as a co-author on the study, also had a thought on the bans’ effect.

    “A ban may be circumvented by going outside or staying home, whereas avoiding a price increase might take more effort,” he pointed out.

    Based on results from this study, raising cigarette prices appears to be a better strategy for encouraging smoking cessation across all ages.

    “More consistent tax policy across the United States might help encourage more older adults to quit smoking,” Mayne said.

    “Given our findings, if an additional one dollar was added to the U.S. tobacco tax, it could amount to upwards of one million fewer smokers,” Auchincloss said. “Short of federal taxes, raising state and local taxes and creating minimum price thresholds for tobacco should be essential components of a comprehensive tobacco control strategy — particularly in places with high tobacco prevalence.


  9. Customized, frequent emails show promise in aiding tobacco cessation

    May 27, 2017 by Ashley

    From the American Cancer Society press release:

    Smokers who received frequent, tailored emails with quitting tips, motivational messages, and social support had cessation rates rivaling that of the most effective medication available for cessation, according to a new American Cancer Society study. The study appears in Tobacco Control.

    New communication technologies have the potential to provide more cheaply the same kinds of social and other support that have previously proven effective in tobacco cessation. Telephone counselling has been shown to be effective for treating tobacco dependence, but its reach is low. Other modalities using internet and smartphone technologies to deliver evidence-based cessation treatment at the population level have begun to expand and have shown promise.

    For the new research, authors studied the use of email, which has the advantage of being read daily or near-daily by most individuals. Email can also provide substantial content within the email, eliminating the need to access a specific website, and with the popularity of mobile phones and tablets, can be read on the go. Emails can also be tailored to address unique characteristics of the recipient.

    To explore whether emails could be effective in cessation, researchers led by J. Lee Westmaas, Ph.D., strategic director of tobacco control research at the American Cancer Society, recruited 1,070 smokers who were planning to quit. They were randomly assigned to receive one of three email protocols: 27 tailored cessation emails; 3 to 4 tailored emails with links to downloadable booklets; or a single non-tailored email. All emails included links to quitting resources. To measure success, abstinence was assessed one, three, and six months post-enrollment by asking whether participants had smoked in the previous seven days.

    Across all three follow-up times, the mean abstinence rate was highest for smokers getting the custom emails (34%), followed by receiving three or four emails (30.8%), and a single email (25.8%). Results were independent of baseline cigarettes per day, interest in quitting, whether there was a fellow smoker in household, and the use of nicotine replacement therapy (NRT) or varenicline, a drug also approved for smoking cessation.

    “The overall quit rate for the main intervention group is about equivalent to the abstinence rates achieved by the most effective medication for cessation,” said Dr. Westmaas. “It appears that the personalization in the emails and their frequency – initially every day then tapering off — gave people the assurance that someone cared about them, and wanted them to succeed. They were receiving daily or nearly-daily guidance about how to deal with issues that come up in their quit attempt, made possible by a relatively simple computer tailoring algorithm.”

    Dr. Westmaas believes the program can be adapted to target particular groups that show disparities in smoking and the health effects of smoking, and plan to conduct a pilot study to help guide an intervention aimed at low socioeconomic status smokers, a group with higher smoking rates.


  10. Study suggests standardized cigarette packaging may reduce the number of people who smoke

    May 3, 2017 by Ashley

    From the Wiley press release:

    A Cochrane Review published today finds standardized tobacco packaging may lead to a reduction in smoking prevalence and reduces the appeal of tobacco.

    According to the World Health Organization, tobacco use kills more people worldwide than any other preventable cause of death. Global health experts believe the best way to reduce tobacco use is by stopping people starting to use tobacco, and encouraging and helping existing users to stop.

    The introduction of standardized (or ‘plain’) packaging was recommended by the World Health Organisation Framework Convention on Tobacco Control (WHO FCTC) guidelines. This recommendation was based on evidence around tobacco promotion in general and studies which examined the impact of changes in packaging on knowledge, attitudes, beliefs and behaviour. Standardized tobacco packaging places restrictions on the appearance of tobacco packs so that there is a uniform colour (and in some cases shape), with no logos or branding apart from health warnings and other government-mandated information; the brand name appears in a prescribed uniform font, colour, and size.

    A number of countries have implemented, or are in the process of implementing, standardized tobacco packaging. Australia was the first country in the world to implement standardized packaging of tobacco products. The laws, which took full effect there in December 2012, also required enlarged pictorial health warnings.

    A team of Cochrane researchers from the UK and Canada have summarized results from studies that examine the impact of standardized packaging on tobacco attitudes and behaviour. They have published their findings in the Cochrane Library.

    They found 51 studies that looked at standardized packaging. The studies differed in the way they were done and also what they measured. Only one country had implemented standardized packaging at the time of this review, so evidence that tobacco use prevalence may have decreased following standardized packaging comes from one large observational study. A reduction in smoking behaviour is supported by routinely collected data from the Australian government. There are data from a range of other studies to indicate that appeal is lower with standardized packaging and this may help to explain the observed decline in prevalence. Researchers did not find any evidence suggesting that standardized packaging may increase tobacco use. No studies directly measured whether standardized packs influence uptake, cessation or whether they prevent former smokers from taking up smoking again.

    The amount of evidence for standardized packaging has increased markedly since the publication of the WHO guidelines in 2008. However, given its recency, there are no data on long-term impact. The amount of evidence will continue to expand as more countries implement standardized packaging and as studies assessing the longer-term effects of the Australian policy become available.

    Cochrane lead author, and Deputy Director of the UK Centre for Tobacco and Alcohol Studies, Professor Ann McNeill from King’s College London, said, “Evaluating the impact of standardized packaging on smoking behaviour is difficult to do; but the evidence available to us, whilst limited at this time, indicates that standardized packaging may reduce smoking prevalence. These findings are supported by evidence from a variety of other studies that have shown that standardized packaging reduces the promotional appeal of tobacco packs, in line with the regulatory objectives set. It would appear that the impact of standardized packaging may be affected by the detail of the regulations such as whether they ban descriptors, such as ‘smooth’ or ‘gold’, and control the shape of the tobacco pack.”

    Co-author Jamie Hartmann-Boyce, from the Cochrane Tobacco Addiction Group, Oxford, UK, added: “Our evidence suggests that standardized packaging can change attitudes and beliefs about smoking, and the evidence we have so far suggests that standardized packaging may reduce smoking prevalence and increase quit attempts. We didn’t find any studies on whether changing tobacco packaging affects the number of young people starting to smoke, and we look forward to further research on this topic.”